Patient outcomes of a clinician curriculum on how to deliver a diabetes diagnosis.

AIMS: To investigate the effects of a curriculum that teaches medical decision making and interpersonal communication in the context of prediabetes (preDM) and type 2 diabetes (T2DM). METHODS: This evaluation was an active-controlled trial of 56 patients, including patients who received their diagnosis from intervention-trained clinicians or a control group. Patients attended a research appointment for informed consent and collection of baseline measures. Over the following six months, both groups were mailed surveys and informational handouts monthly. Upon conclusion, we recorded the most recent A1c from the patient's record. RESULTS: An analysis of covariance test revealed patients who received a T2DM diagnosis from an intervention-trained clinician reported higher reassurance from the diagnosing clinician and had a higher perception of threat. Although not statistically significant, patients with T2DM in the intervention group had a lower A1c at follow up and patients in the intervention group reported less poor eating and a higher degree of diet decision making. CONCLUSIONS: The curriculum itself does not influence glycemic control, but our results demonstrate the positive impact on patients of the curriculum to teach critical skills to clinicians delivering a diabetes diagnosis.

Integrative Medicine: Manual Therapy.

Manual therapy, or manipulative therapy, is performed primarily by osteopathic physicians, chiropractors, and physical therapists to relieve pain and improve function. As safe prescribing of opioids has become a concern and nondrug therapies for pain management are used more widely, manual therapy has become an attractive treatment option for many patients. A variety of techniques are used, including myofascial release, strain-counterstrain, muscle energy, high velocity/low amplitude, Still, and others. The most common conditions for which patients seek manual therapies are back pain, neck pain, and extremity problems. These therapies also are used to manage many other conditions. Studies show that, in general, manual therapies may improve pain and function in the short and moderate term in patients with acute and chronic back pain, neck pain, rotator cuff conditions, and temporomandibular joint disorders. These therapies also are used in patients with sciatica, migraine, carpal tunnel syndrome, pregnancy-related pelvic girdle pain, and infantile colic. Manual therapies may result in improvements in these conditions, but there is no high-quality research to confirm their benefits. Many studies show benefits that are similar to those of other commonly used therapies, or that are not superior to the benefits shown with sham manipulation.

Integrative Medicine: Acupuncture.

Acupuncture is used to manage pain and a variety of medical and psychological conditions. It modulates nociceptive areas of the brain, affects neuropeptide and purinergic signaling, and stimulates production of opioid neuropeptides. There are many types of acupuncture, including traditional, dry needling, laser, auricular, scalp, Japanese, and Korean. There is evidence that traditional acupuncture is effective in the management of many conditions, with strong evidence of benefit for chronic back pain and osteoarthritis-related knee pain. In the United States, the conditions most commonly managed with acupuncture are low back pain, depression, anxiety, headache, and arthritis. There are no absolute contraindications. Relative contraindications include frailty and febrile illness. Acupuncture should not be used in areas of skin infection or breakdown. Acupuncture typically is avoided during the first trimester of pregnancy. Reports of serious adverse effects are rare but include pneumothorax, infection, organ or tissue injuries, and seizures. Serious adverse effects of electroacupuncture (eg, skin burns, pacemaker or implantable cardioverter-defibrillator dysfunction) are limited to case reports. Thirty-three states in the United States consider acupuncture to be within the scope of practice of physicians. Other states require specific acupuncture training. Medicare provides coverage for acupuncture for management of chronic low back pain.

Integrative Medicine: Herbal Supplements.

Various herbal medicines have been used around the world for more than 5,000 years. Herbal medicines, or herbal supplements, are defined as any products originating from plants and used to preserve or recover health. In the United States, the popularity of herbal supplements has increased in the last several decades. Many physicians do not ask patients about herbal supplement use, and one-third of patients do not inform their physician about supplement use. However, physicians should ask, because although many supplements are considered low risk and safe, some have significant risks of adverse effects. For example, St John's wort (Hypericum perforatum) can have significant drug interactions with prescription or over-the-counter drugs. The effectiveness of herbal supplements in the management of specific conditions varies. For some conditions, there is robust clinical data supporting the use of specific herbal supplements, but for other conditions there is poor or insufficient data. The content and safety of herbal supplements are the purview of the Food and Drug Administration (FDA). However, the FDA primarily responds to after-the-fact reports of postmarketing safety concerns. When an herbal supplement-related adverse effect is suspected, patients or physicians should report it to the FDA via the MedWatch reporting system.

Integrative Medicine: Cannabis and Cannabis-Related Drugs.

Cannabis is a genus of flowering herbs in the Cannabaceae family. Federal law defines dried plant material preparations of the subspecies Cannabis sativa as marijuana. The term cannabis refers to all products derived from Cannabis plants. The active compounds in cannabis are cannabinoids, which include delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is the psychoactive component, whereas CBD has no psychoactive effects. There are three Food and Drug Administration (FDA)-approved cannabis-related drugs. Dronabinol and nabilone (Cesamet) are approved for chemotherapy-induced nausea and vomiting; cannabidiol (Epidiolex) is approved for two pediatric epilepsy syndromes. FDA-approved cannabis-related drugs, marijuana, and cannabis formulations have been studied for the management of other conditions and symptoms (eg, cachexia, chemotherapy-induced nausea and vomiting, chronic pain, muscle spasticity) and have shown varying effectiveness. CBD formulations have been shown to be effective for certain forms of epilepsy. However, marijuana, cannabis-containing products, and cannabis-derived products in general are not approved by the FDA for any indication. Adverse effects include impaired executive function, cognition, and driving. Physicians can recommend use of marijuana under medical marijuana laws but cannot prescribe it, as it is classified as a Schedule I controlled substance. Laws regulating use of marijuana and cannabis products vary among states.

Toward a model of shared meaningful diagnosis.

OBJECTIVES: The purpose was to explain the process of diabetes-related diagnosis that prompts patient action (behavior change or treatment adherence). A secondary purpose was to identify barriers/gaps that prevent those outcomes. METHODS: Using a grounded theory approach, we explored diagnosis from the patient's perspective and through the lens of the electronic health record (EHR). A thematic analysis was conducted on interview and EHR data from 28 patients, using the constant comparative method. RESULTS: The emerging model of shared meaningful diagnosis included four stages: stimulus to screen, medical decision making, medical information transfer, and patient sensemaking. Barriers to a meaningful diagnosis emerged in clinical documentation, clinician communication, and patient sensemaking. CONCLUSIONS: This study expands current understanding of "diagnosis," suggesting additional stages between diagnostic labeling and disease management. The additional stages of medical information transfer and patient sensemaking are critical steps to a shared meaningful diagnosis that could enable teamwork among the patient and healthcare team. PRACTICE IMPLICATIONS: To sustain meaningful diagnosis for the patient, clinicians should document what language they used to explain the diagnosis to the patient so that subsequent clinicians can use similar language. Clinicians who work as a team should unify their approach to discussing prediabetes.

How Family Physicians Practice the Principle of Remission Along the Glycemic Continuum.

INTRODUCTION: Recent evidence reveals that diabetes and prediabetes (preDM) can be reversed to normal glucose regulation (NGR) through significant weight loss, but how physicians clinically identify the principles of partial and complete remission of diabetes is largely unknown. METHODS: As part of the cross-sectional omnibus survey conducted in March 2019 at a professional annual meeting in the United States, physician participants answered case scenario questions about the diagnosis and documentation of patients with preDM and type 2 diabetes (T2DM). RESULTS: Of the registered conference attendees, 387 (72.7%) responded. When presented with the initial case of preDM, 201 physicians (70.8%) selected R73.03 Prediabetes. In a follow-up encounter with improved lab results, 118 physicians (58.7%) indicated that they would not chart any diabetes-related code and 62 (30.8%) would chart preDM again. When presented with the case of T2DM, 256 physicians (90.1%) indicated E11.0-E11.9 Type 2 Diabetes. In the follow-up encounter, only 38 (14.8%) coded a diagnosis reflecting remission from T2DM to prediabetes and 211 (82.4%) charted T2DM. CONCLUSION: Physicians may be reluctant to document diabetes regression as there is little evidence for long-term outcomes and "downgrading" the diagnosis in the medical record may cause screenings to be missed. Documenting this regression in the medical record should communicate the accurate point on the continuum of glucose intolerance with both the patient and the care team.

Diabetes ROADMAP: Teaching Guideline Use, Communication, and Documentation When Delivering the Diagnosis of Diabetes.

Introduction: Most interventions to date regarding breaking bad news focus on late-stage disease or disclosing a cancer diagnosis. Little attention has been given to delivery of chronic metabolic disease diagnoses such as prediabetes/type 2 diabetes. Methods: Informed by the American Diabetes Association standards of care and formative research conducted by our research team, we developed this curriculum through the six-step approach to curriculum development. The curriculum consists of a 2- or 3-hour intervention that teaches medical decision-making, interpersonal communication, and clinical documentation in the context of prediabetes and type 2 diabetes followed by role-play and clinical practice. Results: Across three cohorts, 53 clinicians completed the curriculum. Across the three iterations, learners rated the curricular intervention as worthwhile and delivered at an appropriate level. In a community hospital setting, learners scored significantly higher on a knowledge check than did a control group of six clinicians (p < .001). Learners in the community hospital also indicated high response efficacy and self-efficacy. At the academic medical center, simulated patients indicated high measures on the Diabetes Health Threat Communication Questionnaire. Discussion: The moment of diagnosis presents a key opportunity to affect patients' perceptions of the disease. This curriculum guides clinicians in making the most of diagnosis delivery. Pairing of qualitative, patient-centered research alongside the iterative curriculum design process allows the curriculum to be adaptable and scalable to multiple settings and learner types.

Residency Leader Motivations to Engage Residents and Residency Faculty in Scholarship: A Qualitative Study.

BACKGROUND AND OBJECTIVES: Research shows that limited time, lack of funding, difficulty identifying mentors, and lack of technical support limit resident and faculty ability to fully participate in scholarly activity. Most research to date focuses on medical student and resident attitudes toward research. This study aimed to understand the underlying attitudes of family medicine residency (FMR) leaders toward scholarship. METHODS: Two focus groups of family medicine residency leaders were conducted in March 2018. The sample (N=19) was recruited through the membership directory of the Family Physicians Inquiry Network. RESULTS: Leaders shared positive attitudes toward scholarship; however, motivation to engage residents and residency faculty in scholarship diverged. Motivations for promoting scholarly activity among participants were either extrinsic (through ACGME, program graduation, or promotion requirements) or intrinsic (through personal interest and natural drive). CONCLUSIONS: Emerging themes illustrate differences in how FMR program leaders perceive the role of scholarship in residency programs. As programs aim to increase research and scholarship, more attention must be paid to the motivating messages communicated by the program's leadership.

Turning Points as Opportunities to Partner with Patients Living with type 2 Diabetes or Prediabetes.

INTRODUCTION: Understanding patients' perspectives about their diabetes and what causes those perspectives to shift is critical to building a treatment strategy with the patient and facilitating patient self-management behavior. Key "turning points" can provide crucial opportunities to enact a change in perspective. The goal of this study is to identify "turning points" that have significance to diabetes-related health. METHODS: Research coordinators interviewed 33 patients aged 25 to 65 diagnosed with type 2 diabetes mellitus or prediabetes at medical centers in Augusta, Georgia, and Las Vegas, Nevada. Retrospective interview technique and turning point analysis was employed to plot health or diabetes management changes from diagnosis up to the present day. The constant comparative method was used to conduct a thematic analysis. Axial coding identified properties characterizing each turning point. RESULTS: Patients reported 5 interrelated turning points occurring at various times after diagnosis: 1) gaining knowledge, either through patients own research and/or a health care class; 2) making lifestyle changes, including exercising and healthier eating; 3) encountering a life-changing event/transition, including events that derailed healthy behavior, motivated health behavior, and removed barriers to enacting healthy behavior; 4) receiving social support, either through holding patients accountable or encouraging them to enact healthy behavior; and 5) interacting with clinicians, such as medication changes or behavior changes critical to disease management. DISCUSSION: These turning points provide specific moments throughout diabetes care in which family physicians can effectively partner with patients. By prompting, facilitating, or attending to these turning points, family physicians can partner with patients throughout diabetes care.

How patients make sense of a diabetes diagnosis: An application of Weick's model of organizing.

AIMS: To identify communication cycles patients use to make sense of a diabetes diagnosis and barriers patients encounter in their sensemaking process. METHODS: Researchers conducted interviews with 33 participants with type 2 diabetes mellitus or prediabetes at medical centers in Georgia and Nevada. A thematic analysis using the constant comparative method identified communication cycles. RESULTS: Patients reported engaging three communication cycles to make sense of the diagnosis: (1) interacting with healthcare clinicians; (2) seeking information online; and (3) taking a nutrition/diabetes management class. Patients reported system-level barriers that impact sensemaking: (1) lack of consistent or routine care; and (2) lack of access to resources. CONCLUSION: Results here reinforce the theoretical proposition that receiving a diagnosis is an equivocal process that requires patients to make sense of new information through communication cycles. Patients in this sample repeatedly described communication cycles to interpret this new information rather than relying on assembly rules. Clinicians can promote patient understanding of diabetes and self-management by taking time to explain the diagnosis, maintaining consistent care, providing guidance to online sources, and ensuring patients have access to diabetes education.

The relationship between patient perceptions of diabetes and glycemic control: A study of patients living with prediabetes or type 2 diabetes.

OBJECTIVE: This study aims to identify differences in how patients living with prediabetes (preDM) or type 2 diabetes (T2DM) perceive their illness. METHODS: Following chart review, a cross-sectional survey was administered to patients diagnosed with preDM or T2DM at two US medical centers. RESULTS: Among 757 respondents, multivariate tests demonstrate that patients living with T2DM have an overall different personal model of disease than patients living with preDM. Patients who have been diagnosed with T2DM report a better understanding of their disease and perceive it to be more chronic in nature than patients living with preDM. Findings revealed a potential but less significant difference in perceived seriousness. CONCLUSIONS: In this first application of personal models of disease to prediabetes, results inform implications for clinicians to talk with patients about preDM. Patients living with preDM indicate less understanding of the "disease" and perceive it to be less "chronic," which may result from unclear clinician communication about preDM. PRACTICE IMPLICATIONS: When clinicians talk to patients about prediabetes, they should present the risk factor within the spectrum of glucose tolerance. Although labeled a risk factor, clinicians should emphasize that prediabetes remains a serious concern that will not lessen without intervention.

Geographic and Race/Ethnicity Differences in Patient Perceptions of Diabetes.

OBJECTIVES: The present study takes a culture-centered approach to better understand how the experiences of culture affect patient's perception of type 2 diabetes mellitus (T2DM). This study explores personal models of T2DM and compares personal models across regional and race/ethnicity differences. METHODS: In a practice-based research network, a cross-sectional survey was distributed to patients diagnosed with T2DM at medical centers in Nevada and Georgia. In analyses of covariance, controlling for age, health literacy, and patient activation, geographic location, and race/ethnicity were tested onto 5 dimensions of illness representation. RESULTS: Among 685 patients, race/ethnicity was significantly associated with lower reported understanding diabetes ( P < .01) and less perceived longevity of diabetes ( P < .001). Geographic location was significantly associated with seriousness of the disease ( P < .005) and impact of diabetes ( P < .001). CONCLUSION: Non-Hispanic White Americans report greater understanding and perceive a longer disease course than non-Hispanic Black Americans and Asian Americans. Regionally, patients in Nevada perceive T2DM as more serious and having more impact on their lives than patients living in Georgia. Primary care physicians should elicit patient perceptions of diabetes within the context of the patient's ethnic and geographic culture group to improve discussions about diabetes self-management. Specifically, primary care physicians should address the seriousness of a diabetes diagnosis and the chronic nature of the disease with patients who belong to communities with a higher prevalence of the disease.

Exploring patient perspectives of prediabetes and diabetes severity: a qualitative study.

Objective: This qualitative study sought to identify and describe patients' variant perceptions of disease severity after receiving a type 2 diabetes (T2DM) or prediabetes (preDM) diagnosis. Design: Researchers interviewed 29 patients from two US medical centers to ascertain perceptions of severity. We used the constant comparative method from a grounded theory approach to identify themes from patients' perspectives that inform their disease severity. This approach was used to help translate research to practice and ultimately identify intervention strategies informed by authentic experiences of preDM and T2DM patients. Results: Perceptions of disease severity fell into two groups: high and low severity. Patients diagnosed with T2DM and preDM emerged in both groups and were comparative in terms of sample size, gender, and ethnic diversity. Several factors contributed to patients' beliefs, including what they were told about the disease, observations from experiences within their own social network, and information from formal diabetes classes and their own research. The two perspectives diverged when patients described how their belief was informed by three thematic properties or personal factors: (i) fears; (ii) clinician communication; and (iii) social comparisons. Conclusions: Beliefs about severity are influenced by patients' fears, interactions with clinicians, and experiences within their social networks. These findings show that when interacting with patients with T2DM or preDM, clinicians should elicit patient perceptions of disease severity so they may then tailor the discussion to address these perceptions and help patients grasp the severity of these conditions.

Relationship of Training in Acupuncture to Physician Burnout.

BACKGROUND: Physician burnout is an ongoing problem that affects both physician wellbeing and patient care. Burnout is characterized by emotional exhaustion and depersonalization. Studies have explored ways to prevent and alleviate burnout. Receiving training in acupuncture may reduce physician burnout. OBJECTIVE: The purpose of this study is to determine if acupuncture training is associated with less patient depersonalization and less emotional exhaustion among physicians. METHODS: These self-reported data were collected from a cross-sectional survey of family physicians at the Uniformed Services Academy of Family Physicians 2017 conference. Physicians answered questions regarding their level of acupuncture training as well as questions about burnout (depersonalization and emotional exhaustion). RESULTS: The overall response rate was 66% (325/492). Of these, 233 cases provided complete datasets. In a model controlling for years' practice and clinical pace, acupuncture training was significantly associated with decreased depersonalization, F (1, 194) = 5.82, P < .05. CONCLUSION: Study data show an association between decreased physician depersonalization and acupuncture training, suggesting acupuncture training may be a helpful strategy to reduce family physicians' depersonalization of patients.

Effect of water-soluble cinnamon extract on electrocardiographic parameters: An analysis of the CiNNaMON trial.

OBJECTIVE: To ensure that cinnamon extract does not cause electrocardiographic (ECG) effects in patients with prediabetes. DESIGN: A subgroup analysis was carried out on data from 103 prediabetic patients participating in the "Effect of Lifestyle Intervention Plus Water-Soluble Cinnamon Extract on Lowering Blood Glucose in Prediabetics" trial. The trial was a randomized, double-blind, placebo-controlled trial comparing cinnamon extract versus placebo in prediabetic adults who committed to participate in a standard-of-care, aggressive lifestyle therapy program. SETTING: Family Medicine Residency, Mike O'Callaghan Military Medical Center; Family Medicine Residency, David Grant Medical Center, Travis AFB; Wilford Hall Ambulatory Surgical Center, Family Medicine Residency; Eglin AFB, Family Medicine residency; Offutt AFB, Family Medicine Residency. MAIN OUTCOME MEASURES: QTc interval, QT interval, PR interval, QRS duration and heart rate from ECGs at baseline, 3 months, and 6 months. RESULTS: Analysis of the ECGs showed no time-matched intra-group differences in any of the ECG parameters (QTc interval, QT interval, PR interval, QRS duration and heart rate; all p-values >0.05). CONCLUSIONS: Use of cinnamon extract in prediabetic patients does not affect electrocardiographic measures.

Critical Factors to Practicing Medical Acupuncture in Family Medicine: Patient and Physician Perspectives.

INTRODUCTION: Although an increasing number of physicians are completing medical acupuncture training, only half of those physicians are able to successfully incorporate acupuncture into practice. We conducted a qualitative study to identify the factors and barriers that can enhance and impede physicians' delivery of and patients' engagement in medical acupuncture within the family medicine clinic. METHODS: We conducted interviews with 15 family physicians and 17 patients in a US family medicine clinic that has integrated medical acupuncture into its practice. Audio recordings were transcribed and analyzed by 2 members of the study team in ATLAS.ti, using the constant comparative method. RESULTS: We identified 3 physician themes of factors/barriers that impact delivery/engagement: 1) patients' aversion to needles, 2) time challenges, and 3) access to resources. We identified 3 additional themes from patient interviews: 1) appointment access; 2) wanting noninvasive, no side effects alternative; and 3) openness to anything. DISCUSSION: The factors and barriers reported by physicians/patients help illustrate conditions needed to enhance physicians' ability to provide acupuncture and patients' willingness to engage and sustain it. Participants' experiences help to illustrate strategic approaches to managing these barriers-strategies that can be used by other individuals/institutions to enhance care delivery and patient engagement.

Abdominal Circumference Versus Body Mass Index as Predictors of Lower Extremity Overuse Injury Risk.

BACKGROUND: Abdominal circumference (AC) is superior to body mass index (BMI) as a measure of risk for various health outcomes. Our objective was to compare AC and BMI as predictors of lower extremity overuse injury (LEOI) risk. METHODS: Retrospective review of electronic medical records of 79,868 US Air Force personnel over a 7-year period (2005-2011) for incidence of new LEOI. Subjects were stratified by BMI and AC. Injury risk for BMI/AC subgroups was calculated using Kaplan-Meier curves and Cox proportional-hazards regression. Receiver operating characteristic curves with area under the curve were used to compare each model's predictive value. RESULTS: Cox proportional-hazards regression showed significant risk association between elevated BMI, AC, and all injury types, with hazard ratios ranging 1.230-3.415 for obese versus normal BMI and 1.665-3.893 for high-risk versus low-risk AC (P < .05 for all measures). Receiver operating characteristic curves with area under the curve showed equivalent performance between BMI and AC for predicting all injury types. However, the combined model (AC and BMI) showed improved predictive ability over either model alone for joint injury, overall LEOI, and most strongly for osteoarthritis. CONCLUSIONS: Although AC and BMI alone performed similarly well, a combined approach using BMI and AC together improved risk estimation for LEOI.